Module 2

which instruction would the nurse include in the teaching plan for a client who has a new colostomy and is learning how to care for the skin around the stoma? a. Cut an opening about 1/3 inch (0.85 cm) larger than the stomal pattern b. avoid the use of soap and other irritating agents c. eat yogurt and drink buttermilk and parsley d. empty the pouch before it is one-third full

d. empty the pouch before it is one-third full the wafer should be cut an opening about 1/8 to 1/16 inch (0.32-0.16 cm) soap is the agent of choice yogurt / buttermilk help with odor but not skin breakdown

The RN delegates a task to a LPN. Which client task can be assigned to the LPN?

Client B A and C = RN D = UAP

A client with a history of ulcerative colitis has a large portion id the large intestine removed, and an ileostomy is created. For which potential life-threatening complication would the nurse assess the client after this surgery? a. infection caused by the excretion of feces b. injury caused by exposed intestinal mucosa c. altered bowel elimination caused by the ostomy d. limited water reabsorption caused by the removal of the intestine

d. limited water reabsorption caused by the removal of the intestine electrolyte imbalance

The nurse is caring for a client 5 days after the surgical creation of a colostomy. The client has displayed signs of depression since the surgery. The nurse would determine that there is some movement toward adaptation to change in body image when the client exhibits what behavior? a. the client discusses the necessity of the colostomy b. the client requests the nurse to change the dressing c. the client looks at the face of the nurse during care d. the client stares at the stoma during dressing changes

d. the client stares at the stoma during dressing changes

The nurse is changing the dressing of a postoperative client. Another client has fallen near the nursing station and is unconscious. Which is the priority nursing action in this situation? a. attend to the client who lost consciousness b. delegate the dressing change to the nursing assistant c. delegate the care of the unconscious client to the nursing assistant d. complete the dressing, because the open wound may increase infection risk

a. attend to the client who lost consciousness

Which action would the nurse take first after observing serosanguineous drainage on the abdominal dressing of a client in the PACU who had abdominal cholecystectomy? a. change the dressing b. reinforce the dressing c. replace the tape with montgomery ties d. support the incision with an abdominal binder

b. reinforce the dressing a = risk for infection c = premature, use ties if freq. changes are expected d = rarely prescribed

Which assessment finding would the nurse report to the health care provider when giving immediate postoperative care to a client with a newly placed ostomy? a. moderate edema of the stoma b. excessive gas issuing from the stoma c. blanching, dark red to purple color of the stoma d. small amount of blood oozing from the stoma

c. blanching, dark red to purple color of the stoma sign of inadequate blood supply

Which food or drink would the nurse instruct a client with a new colostomy to avoid because it produces large amounts of gas? a. milk b. cheese c. coffee d. cabbage

d. cabbage

A client has a large, open abdominal wound. The HCP's prescription states to cleanse the wound with normal saline, pack it with damp gauze, cover with abdominal pads, and secure with montgomery straps twice a day. Which step would the nurse take to maintain sterility when changing the dressing? a. use two square gauze pads to cleanse the wound, one for each half of the wound, b. apply new montgomery straps each time the dressing is changed c. hold the wet gauze with the tips of the forceps higher than the wrist d. cleanse the wound with wet, sterile gauze from the center of the wound outward.

d. cleanse the wound with wet, sterile gauze from the center of the wound outward.

The nurse is caring for a client after surgical creation of an ostomy. The nurse observes that the stool is formed. The stool is this consistency in which part of the colon? a. Ileum b. Ascending c. Transverse d. Descending

D. Descending

which intervention would the nurse do before formulating a teaching plan for a child who is to undergo ostomy surgery? a. assess the child's developmental level b. determine the family's comprehension of the procedure c. provide a list of available community resources to the family d. collaborate with the school in ensuring the child's smooth return

a. assess the child's developmental level

When teaching a client with a new colostomy about appliance care and maintenance, which information would the nurse include? SATA a. change the ostomy pouch on a routine basis b. replace the ostomy wafer weekly or sooner as needed c. remove the ostomy pouch when showering d. empty the ostomy pouch when 3/4 full of stool or gas e. empty the ostomy pouch before exercise and at bedtime

a. change the ostomy pouch on a routine basis b. replace the ostomy wafer weekly or sooner as needed e. empty the ostomy pouch before exercise and at bedtime empty when 1/3 full twice weekly changes are typical

At which time would the nurse plan to administer morphine 2 mg by mouth every 2 hours as needed to a client who has burns on 55% of the body surface and requires dressing changes? a. 15 minutes before the dressing change b. 60 minutes before the dressing change c. along with stool softener each time it is administered d. only if the client rates pain between 8 and 10 on the pain scale

b. 60 minutes before the dressing change

Which statement by the nursing student about the discharge instructions to be given to a postoperative client indicates that the nurse needs to intervene? a. I should teach the client about using topical antibiotics b. I should teach the client about how to change wound dressings c. I should instruct the client about signs and symptoms of an infection d. I should instruct the client that the non-oozing wound should be cleaned with saline solution

d. I should instruct the client that the non-oozing wound should be cleaned with saline solution No, use normal soap and plain water

a client with a newly formed colostomy, secondary to cancer of the rectum, received nstructions regarding ostomy care and management. Which client statement indicates understanding of colostomy care? a. I will call the clinic and report if I notice a loss of sensation to touch in the stoma tissue b. I will call the clinic and report when mucus is passed from the stoma between irrigations c. I will call the clinic and report expulsion of flatus while the irrigating fluid is running out d. I will call the clinic and report if I have difficulty inserting the irrigating tube into the stoma

d. I will call the clinic and report if I have difficulty inserting the irrigating tube into the stoma